A 47-Year-Old Man With a History of Alcohol-Induced Chronic Pancreatitis

Juan Carlos Munoz, MD; William J. Salyers, Jr, MD, MPH


May 11, 2016

Physical Examination and Workup

On physical examination, his oral temperature is 98.6°F (37°C), his pulse is regular but tachycardic at a rate of 107 beats/min, and his blood pressure is low, at 69/37 mm Hg. Significant orthostatic changes are noted in the patient's pulse and blood pressure. The patient is tachypneic, with a respiratory rate of 24 breaths/min, but he is not in any acute respiratory distress. At the time of initial evaluation, he appears pale and weak, and dry oral mucosa is noted. The examination of the head and neck is normal except for pale conjunctiva. His lungs are clear to auscultation. The cardiac evaluation reveals tachycardia, with normal S1 and S2 heart sounds.

The abdominal examination is significant for mild epigastric and left upper quadrant tenderness, without rebound or guarding. He is noted to have mild abdominal distension as well as hyperactive bowel sounds. The patient's peripheral arterial pulses in the upper and lower extremities are poorly palpable but equal. A rectal examination reveals dark-red stool in the rectum. The rest of the physical examination is unremarkable, except for external hemorrhoids that are not actively bleeding or thrombosed.

The initial workup includes normal chest x-ray and electrocardiography findings that only reveal sinus tachycardia. Laboratory testing on admission reveals a hemoglobin level of 3.9 g/dL (39 g/L; the patient's last hemoglobin test, which was performed 4 weeks ago, was 14.9 g/dL [149 g/L]). His platelet count is measured at 389 × 103/μL (389 × 109/L), prothrombin time is 1.3 seconds, and his partial thromboplastin time is 26 seconds. Values obtained on measurement of the patient's liver enzymes are within normal limits.

The patient is treated in the ED with intravenous fluids, packed red blood cell transfusion, and intravenous proton pump inhibitors. A gastroenterologist is consulted for endoscopic evaluation. As a result of profuse bleeding, however, no endoscopy is performed. The patient is instead scheduled for a technetium Tc 99m-labeled red blood cell scintigraphy, which reveals bleeding from the second part of the duodenum. The patient is stabilized hemodynamically, and another transfusion is performed. He is subsequently able to undergo the upper endoscopy.

The image seen in the Figure is recorded at the level of the ampulla of Vater.


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